shoulder pathomechanics
TRANSCRIPT
SHOULDER PATHOMECHANICS
Musculoskeletal Physical Examination With
Chimwemwe Masina
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SHOULDER PATHOMECHANICS
Areas of coverage:Review of shoulder anatomyPhysical examination
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THE PECTORAL GIRDLE Shoulder(pectoral) girdle
comprises of two bones= clavicle and scapula Form sternoclavicula(SC),
coracoclavicula(CC) and glenohumeral(GH) joints + scapulohoracic(ST) articulation
Shoulder joint, GH, is a ball and socket joint and hence allows the hand to be precisely positioned in space, maximizing functionality
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EXAMINATION PROCEDURE
ObservationPalpationRange of motion (ROM)
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OBSERVATION
Start by looking at the normal (or more normal) side. Note any scars, obvious asymmetry, discoloration, swelling, or muscle asymmetry.
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CRITICAL EXTERNAL LANDMARKS CONTAIN THE:
Acromion Clavicle Scapula Deltoid muscle Supraspinatus Infraspinatus Teres Minor
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PALPATION
Gently palpate around the shoulder, touching each of the landmarks noted above. Take note of pain.
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RANGE OF MOTION
In the case of no symptoms, test both sides simultaneously. Otherwise, start with the normal side.
There are active and passive ranges of motion
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ACTIVE ROM (A.ROM)
1. Abduction: Determine the extent to which the patient can abduct their arm.
Patient should be able to lift their arm in a smooth, painless arc to a position with hand above their head.
Normal range is from 0 to 180 degrees.
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ACTIVE ROM (A.ROM) 2. Adduction and Internal
rotation (Appley Scratch Test) Ask the patient to place their
hand behind their back, and instruct them to reach as high up their spine as possible.
Note the extent of their reach in relation to the scapula or thoracic spine.
They should be able to reach the lower border of the scapula (~ T 7 level).
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ACTIVE ROM (A.ROM)3.Abduction and External
rotation: Ask the patient to place
their hand behind their head and instruct them to reach as far down their spine as possible.
Note the extent of their reach in relation to the cervical spine, with most being able to reach ~C 7 level.
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ACTIVE ROM (A.ROM)
4.Forward flexion: Ask the patient to trace
out an arc while reaching forward (elbow straight).
They should be able to move their hand to a position over their head.
Normal range is 0 to 180 degrees.
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ACTIVE ROM (A.ROM)
5.Extension: Ask the patient to
reverse direction and trace an arc backwards (elbow straight).
They should be able to position their hand behind their back.
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PASSIVE ROM(P.ROM)
If pain with A.ROM, repeat the movements with P.ROMHave patient relax & place one of your hands on their
shoulder. Gently grasp the humerus in your other hand and
move the shoulder through the range of motions described above.
Note if there is pain, and if so which movement(s) precipitates it.
Also note if you feel crepitus with the hand resting on the shoulder
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P.ROM Pain/limitation on active ROM but not present with passive
suggests a structural problem with the muscles/tendons firing with active ROM but not passive. Crepitus suggests DJD.
Note limitations in any movement direction Where exactly in the arc does this occur? Is it due to pain or weakness? How does it compare with the other side? Determining precise etiology can be defined using the tests
below, though often times significant amount of overlap between several conditions occur.
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IMPINGEMENT, ROTATOR CUFF TENDONITIS AND SUB-ACROMIAL BURSITIS
Mostly relatedImpingement:
Dynamic & can result in tendonititis & bursitis as well
Shoulder pain is common When subacromial space
is narrowed, 4 tendons of SITS muscles get impinged upon under the subacromial bursa
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IMPINGEMENT
Resulting friction inflames the tendons as well as the subacromial bursa.
Net result is shoulder pain, especially when raising the arm over head (e.g. swimming, reaching for something on a top shelf, arm positioning during sleep).
Over time, chronic irritation to the tendons can lead to fraying, tears, and even complete disruption
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IMPINGEMENT
Sub-acromial Palpation:First, identify the acromium by walking your
fingers along the spine of the scapula until you reach its lateral endpoint, which is the acromium.
Then gently palpate in the region of the sub-acromial space (see picture below).
Palpation may cause pain if the tendons/bursa are inflamed.
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IMPINGEMENT TEST 1.Neers Test for impingement: Place one of your hands on
the patient's scapula, and grasp their forearm with your other.
The arm should be internally rotated such that the thumb is pointing downward.
Gently flex the arm, positioning the hand over the head.
Pain suggests impingement.
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IMPINGEMENT 2.Hawkin's (for more subtle
impingement) Raise the patient's arm to 90
degrees forward flexion. Then rotate it internally (i.e.
thumb pointed down). This places the greater
tubercle of the humerus in a position to further compromise the space beneath the acromion.
Pain with this maneuver suggests impingement.
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EVALUATION OF ROTATOR CUFF MUSCLES
Supraspinatus muscle The mostly injured of the
shoulder muscle Empty can test:
1.Have the patient abduct their shoulder to 40 degrees, with 30 degrees forward flexion and full internal rotation (i.e. turned so that the thumb is pointing downward). This position prevents any contribution from the deltoid to abduction.2.Direct them to forward flex the shoulder, without resistance. 3.Repeat while you offer resistance.
Partial tear of the muscle or tendon, the patient will experience pain & perhaps some element of weakness with the above maneuver.
Complete disruption of the muscle will prevent the patient from achieving any forward flexion.
These patients will also be unable to abduct their arm, and instead try to "shrug" it up using their deltoids to compensate.
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DROP ARM TEST FOR SUPRASPINATUS TEARS
: Adducting the arm depends upon both the deltoid and supraspinatus muscles.
When all is working normally, there is a seamless transition of function as the shoulder is lowered, allowing for smooth movement.
This is lost if the rotator cuff as been torn. Specifics of testing: Fully abduct the patient's arm, so that their hand is over their head. Now ask them to slowly lower it to their side. If the supraspinatus is torn, at ~ 90 degrees the arm will seem to suddenly
drop towards the body. This is because the torn muscle cant adequately support movement thru the remainder of the arc of adduction.
Deltoid: Not a muscle of the rotator cuff, but important for the later aspects of abduction and flexion. The supraspinatus is responsible for the early component of abduction. The deltoid is readily visible on exam and not commonly injured.
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INFRASPINATUS AND TERES MINOR (EXTERNAL ROTATORS)
Infraspinatus: Have the patient slightly abduct
(20-30 degrees) their shoulders, keeping both elbows bent at 90 degrees.
Place your hands on the outside of their forearms.
Direct them to push their arms outward (externally rotate) while you resist.
Interpretation: Tears in the muscle will cause weakness and/or pain
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INFRASPINATUS AND TERES MINOR (EXTERNAL ROTATORS)
Teres minor: Have the patient slightly abduct
(20-30 degrees) their shoulders, keeping both elbows bent at 90 degrees.
Place your hands on the outside of their forearms.
Direct them to push their arms outward (externally rotate) while you resist.
Interpretation: Tears in the muscle will cause weakness and/or pain
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SUBSCAPULARIS FOR INTERNAL ROTATION
Gerbers Lift off Test (Subscapularis):
Have the patient place their hand behind their back, with the palm facing out.
Direct them to lift their hand away from their back. If the muscle is partially torn, movement will be limited or cause pain.
Complete tears will prevent movement in this direction entirely.
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Biceps tendonitis
• ….to be continued depending on demand….
• Details of the test can be found on the following link:
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